Friday, November 7, 2014

I have heard quite a bit of good feedback and press about the ASCO/AAHPM palliative oncology meeting in Boston at the end of October (See Pallimed Review One and Two). And I agree; Bravo! Having attending the meeting as a hospice medical director and somewhat retired palliative medical oncologist, my reflections of the meeting are more complicated. Indeed, there was excitement and energy about the possibilities, in clinical and research arenas alike. Especially among physicians, young academic physicians in particular.

For those of us who have migrated around this landscape a bit and have seen slow and fast changes over the last decade, the excitement and energy were palpably tempered by some harsh realities. Those realities really distilled themselves around Dr. Arif Kamal’s (Duke University Palliative Care Division) excellent oral presentation on Saturday October 25: “Prevelence and predictors of burnout among specialty palliative care clinicians in the United States: Results of a national survey”. The results were interesting and straightforward, and not surprising to me: Physician burnout in palliative care is higher-over 62%-than the burnout rate reported in medical oncology-45%-according to a large national survey of over 1,200 hospice and palliative care clinicians*. And over 50% of palliative care physicians expect to leave the field in the next 10 years.

Some may be interested in the subgroup analyses and predictors, but I believe the important message in in the forest, not in the trees. I talked to Dr. Kamal (a native Missourian like me!) and a number of other physician and nurse professionals at the meeting about the stresses and strains of palliative care practice with teams in the oncology and non-oncology settings and in inpatient and outpatient settings. The messages I received were fairly clear-cut and stark. The field is moving forward. There is progress but much work yet needs to be done to serve the needs of the patients and families and the health care system. There aren’t nearly enough clinicians doing this work and being paid to do this work. Hospitals and health care systems are reaping the benefits of the teams (quality improvement, patient satisfaction, and dramatic cost savings/avoidance), but not supporting the teams nearly enough with needed staffing or infrastructure. It isn’t only that programs can’t find the people to fill the positions needed; it is that the hospitals and systems are not creating/funding the needed positions. According to Dr. Kamal, other sources of burnout noted by those palliative care clinicians surveyed include constant justification of our worth to other clinicians and administration (not as much of an issue for oncology teams), lack of mentorship and colleagues, and the emotional toll of the work.

So...the work gets done by hard-working, mission-driven, passionate, committed physicians and nurses and advance practice nurses and social workers and chaplains, but they work very long days (and nights) often more than 5 days a week without the administrative support they need to work smarter and more efficiently and to get them more help. And often they get penalized for working overtime! Interestingly, these same forces are in effect in the medical oncology world, for both hospital-owned and the less common private practices. Profits may be going down somewhat as value goes up, but the system is squeezing the value/profit out of PC programs and Oncology practices,and not paying the price of staffing those hospital programs and clinics with the physicians, nurses, and other clinicians and staff to assure the highest quality of care and job satisfaction for these committed professionals.

Consequently, as we move palliative care more into the ambulatory setting, and more into the oncology setting in a truly integrated way, and discuss primary palliative care vs. secondary palliative care, we MUST engage with the directors and CMOs and CFOs and COOs of these programs. Engage by sharing the burnout data and stories with organizational leadership and also share the quality and fiscal benefits they are receiving now, could receive more of in the future, or could lose to burnout if we don’t take care of ourselves and our teams while we do this critically important work for our population and our health care system. As I noted in my tweet after Dr. Kamal’s presentation:

#pallonc: too much work, not enough support, need to say NO more often, set personal and team limits, share the pain!
— Clay Anderson (@AnglerMD) October 25, 2014

What we do is way too important to have us fall on the sword and then leave no one else to do it. As Dr. Kamal notes in personal communication: “In the business world, we’d be called disruptive innovators. But in medicine, we’re often just referred to as disrupters, interrupters, misfits, etc.”. Let’s move forward with passion, but with limits and firm negotiation befitting of our value to our patient and families, and our health care system.Clay M. Anderson, MD, FACP, FAAHPM is the Medical Director for NorthCare Hospice and Palliative Care in Kansas City, MO. He is also a fantastic angler who can be found on Twitter at @AnglerMD.

Pallimed: A Hospice & Palliative Medicine Blog Founded June 8, 2005.
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